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Table of Contents
CASE REPORT
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 60-62

Was the rapid resolution of a laryngeal granuloma due to high dose double proton pump inhibitor treatment?


Department of Otolaryngology Head and Neck Surgery, Taksim Training and Research Hospital, Istanbul, Turkey

Date of Web Publication19-Sep-2011

Correspondence Address:
Ceki Paltura
Taksim Training and Research Hospital, Siraselviler Street No: 112, Beyoglu, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.85064

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   Abstract 

A laryngeal granuloma (LG) is a benign tumor that usually develops on the cartilaginous vocal process of the vocal cords. Gastroesophageal reflux (GER), hyperfunctional use of the voice, and intubation injury are etiological factors. Patients usually complain of dysphagia, and dysphonia. A 53-year-old male consulted the Taksim Educational and Research Hospital ENT Department, complaining of a 6-month history of hoarseness, dysphagia, and globus sensation. On laryngoscopic examination, a granuloma was found on his left vocal process He was given an anti reflux treatments and advised on vocal hygiene. At the 1-month follow-up, the granuloma had disappeared. A thorough history was taken and disclosed that at time of his first visit, he saw a gastroenterologist for his heartburn and regurgitation and was administered pantoprazole 40 mg once daily. Consequently, the rapid resolution of the granuloma was thought have resulted from the high-dose double PPI treatment.

Keywords: Laryngopharyngeal reflux, intubation injury, laryngeal granuloma, proton pump inhibitors


How to cite this article:
Develioglu ON, Paltura C, Topak M, Kulekci M. Was the rapid resolution of a laryngeal granuloma due to high dose double proton pump inhibitor treatment?. J Laryngol Voice 2011;1:60-2

How to cite this URL:
Develioglu ON, Paltura C, Topak M, Kulekci M. Was the rapid resolution of a laryngeal granuloma due to high dose double proton pump inhibitor treatment?. J Laryngol Voice [serial online] 2011 [cited 2019 Dec 13];1:60-2. Available from: http://www.laryngologyandvoice.org/text.asp?2011/1/2/60/85064


   Introduction Top


A laryngeal granuloma (LG) is a benign tumor that usually develops on the cartilaginous vocal process of the vocal cords. Gastroesophageal reflux (GER), hyperfunctional use of the voice, and intubation injury are etiological factors. GER, the reflux of the gastric contents into the esophagus, occurs in up to 40% of the population. Typical symptoms of GER are heartburn and regurgitation. [3] Some patients complain of atypical symptoms, like a chronic cough, excessive throat clearing, globus sensation, dysphagia, and dysphonia. In these cases, laryngopharyngeal reflux (LPR) disease should be suspected. The American Bronchoesophageal Association distinguished disease due to extra-esophageal reflux in addition to the esophageal effects of the gastric contents. [3],[4] LPR is the main disease in this group and presents with pharyngeal and laryngeal symptoms. Endoscopic findings can facilitate the diagnosis of LPR. Belafsky et al. devised the Reflux Symptom Index (RSI) for the diagnosis and follow-up of LPR. It consists of nine self-assessment questions that analyze the patient's situation. In the RSI, a score of 13 or more indicates LPR. [5],[6] Recently, the Reflux Finding Score (RFS) was developed. It is based on findings compatible with reflux, such as subglottic, vocal cord surface, or posterior commissure abnormalities, ventricular obliteration, granuloma formation, or diffuse laryngeal edema. With the RFS, seven or more points indicate laryngitis, caused by reflux. [6] Once diagnosed, patients are treated with a high-dose proton pump inhibitor (PPI) given twice daily and require speech therapy. [4],[8]


   Case Report Top


A 53-year-old male consulted the Taksim Educational and Research Hospital ENT Department, complaining of a 6-month history of hoarseness, dysphagia, and globus sensation. His RSI score was 16. A routine ear, nose, and throat examination showed no abnormality. On laryngoscopic examination, a granuloma was found on his left vocal process [Figure 1]. The RFS was 9 points. He was not a smoker. He was prescribed lansoprazole 30 mg twice daily, a minimum of 30 min before meals. He was advised on vocal hygiene and to avoid eating foods that contain large amounts of caffeine or fat. At the 1-month follow-up, the granuloma had disappeared [Figure 2]. A thorough history was taken and disclosed that at time of his first visit, he saw a gastroenterologist for his heartburn and regurgitation and was administered pantoprazole 40 mg once daily. Consequently, the rapid resolution of the granuloma was thought have resulted from the high-dose double PPI treatment.
Figure 1: A 53-year-old male with a granuloma at the left vocal process

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Figure 2: The same patient after 1 month of double proton pump inhibitor therapy

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   Discussion Top


Due to difficulty in treating them, laryngeal granulomas cause various problems for patients and physicians. Patients usually complain of pain, globus sensation, hoarseness, throat clearing, post-nasal drainage, painful phonation, and intermittent hemoptysis. [1],[2],[3] Before treating a LG, a thorough etiological and clinical examination is fundamental. Classically, on laryngoscopy, these lesions are usually seen on the vocal process and are usually caused by intubation injury. Additionally, hyperfunctional use of the voice, smoking, chronic cough, infection, allergy, and LPR are etiological factors. [2],[3] Sometimes, LGs are found in patients with no history of intubation injury; in such patients, LPR should be suspected. Delahunty and Cherry were the first to show that a LG could be caused by LPR in an animal model. [1] In some articles, LPR is thought to increase the risk of intubation injury. [4]

Thus, LPR should be considered in patients with a LG with no intubation injury. The evaluation should include the RSI and RFS, 24-h double-probe pH monitoring, barium swallow examination, and other reflux tests. When these tests are not available, patients should be given a PPI twice daily empirically. Additionally, patients should be advised on lifestyle modifications, such as consuming less caffeine and fatty food, stopping smoking, and delaying sleeping for least 2-3 h after meals. The treatment of LPR is more aggressive than that of reflux. Surgically removed granulomas tend to recur frequently. [2],[3] Hoffman et al. designed an algorithm for the treatment of LG. [4] This algorithm primarily consists of PPI treatment plus voice therapy. In resistant cases, it suggests Botulinum toxin treatment and the final step is anti-reflux surgery. [4] The current literature shows that with these treatment modalities, patients usually recover in 2-20 months. [4],[8] For follow-up, patients should undergo a monthly laryngological examination. In patients in whom conservative treatment fails, there is airway obstruction, or the diagnosis is unclear, a biopsy by direct laryngoscopy is recommended. [2]

Abnormal vocal abuse is one cause of LG. Some laryngologists use Botulinum toxin injections in the treatment of LG. This is an office-based procedure in which approximately 10 U of Botulinum toxin A are injected into both vocal cords. This treatment reduces the size of the LG in around 1 month. [4]

In some patients, the LG can recur. These patients need 24-h pH monitoring, because a LG can recur with continuing LPR. Some patients can develop resistance to PPI treatment. In this situation, the omeprazole dosage can be increased to 80 mg daily or an equivalent dose of another PPI can be administered. If medical treatment fails, laparoscopic fundoplication is an alternative. [8]

Our patient was inadvertently given double PPI treatment at high dose and the LG resolved quickly without voice therapy.[8] During the treatment period, he obeyed the rules of vocal hygiene and was at complete vocal rest. This PPI dosage is not toxic. In one study, lansoprazole 600 mg and pantoprazole 240 mg was administered without any serious side effects.[7] The reason for the rapid resolution in our case is not clear. It may have resulted from the double PPI or super-dose PPI use. Therefore, a randomized controlled study should be conducted in a much bigger population.

 
   References Top

1.Delahunty JE, Cherry J. Experimentally produced vocal cord granulomas. Laryngoscope 1968;78:1941-7.  Back to cited text no. 1
    
2.Koufman JA. Contact ulcer and granuloma of the larynx. In: Gates G; ed Current Therapy in Otolaryngology- Head and Neck Surgery. 5 th ed. St. Louis, Mo: CV Mosby; 1993:456-9.  Back to cited text no. 2
    
3.Ulualp SO, Toohill RJ: Laryngopharyngeal reflux: state of the art diagnosis and treatment, Otolaryngol Clin North Am 4:785,2000.  Back to cited text no. 3
    
4.Hoffman HT and others: Vocal process granuloma, Head Neck 23:1061,2001.  Back to cited text no. 4
    
5.Belafsky PC, Postma GN, Koufman JA. Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope, 111:979,2001.  Back to cited text no. 5
    
6.Belafsky PC, Postma GN, Koufman JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111:1313-7.  Back to cited text no. 6
    
7.Richard C. Dart, Medical Toxicology, Third Edition; 2003; 943-944.   Back to cited text no. 7
    
8.Tsunoda K, Ishimoto S, Suzuki M, et al. An effective management regimen for laryngeal granuloma caused by gastroesophageal reflux: Combination therapy with suggestions for lifestyle modifications. Acta Otolaryngol 2007;127:88-92.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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